Medicine For People!

December 2008

The woman with a hole in her heart

There are some patients you never forget, and Eden was one of them. Attractive, childlike, with wind-blown hair, she came into my examination room complaining of a hole in her heart. That spring of 1983 was just beginning, and her light and worn clothing seemed inadequate for the chill of Red Bluff in Northern California. Having no money for a doctor (or for much of anything else), she had found her way to the Tehama County Health Center, the only place in Red Bluff you didn't need a dollar for medical care.

On careful exam I could hear no heart murmur. Her chest X-ray and EKG were normal. There was no hole in her heart. She was coughing and congested, and certainly did have the flu. I explained about atrial septal defects, ventricular septal defects, the EKG, how I knew the chambers of her heart were intact and normal. She swept her light brown hair out of her eyes, looked at the floor, and said "But what can you do about this hole in my heart?" I forced my brain to a slower pace, asked myself to look at the world through her eyes. "How do you know you have a hole in your heart?" "I can feel it."

"The best thing for your heart, then, is to rest and stay warm for a few days."

With a hopeful but weary smile she said she'd try. She was on her way south. She'd come down from British Columbia, and she wasn't surprised she had the flu because she had been sleeping outside and was pretty cold at night. In fact, all she had was what she carried on her back. But that was ok, because she had a really warm jacket, and she fingered the edge of it.

The jacket was pretty light weight, to my eye, and I told her so.

"No," she said, "it's really a special jacket. I had this old heavy coat, but last week some guy up north let me trade it to him for this jacket." She seemed convinced that she'd gotten the best part of the deal, but I had my doubts.

"Look," I said, "I bet our social worker can get you into a warm place to stay tonight." She seemed to recede from me. "No, I need to be going. All that bothers me is this hole in my heart."

Her sadness filled the room and brought home to me the nature of this heart defect, made no better by whoever had taken her heavy coat in exchange for a light jacket, and by God knows whatever else had happened to her before that.

Eden wasn't all that unusual in that clinic. People who had trouble taking care of themselves wound up with us. We served the losers of the economic battle. Federal payments for Medicaid and Medicare covered part of the cost, and a grant from Sacramento covered the rest. Three doctors and one nurse midwife hustled mightily to meet the needs of our patients, and diverse needs they were.

Kidney stones, minor trauma, pneumonia, colds and flu, pregnancy and its complications — we saw it all. Sewing up minor lacerations and dealing with fractures were all in a days works, but when a shooting was involved — well, that was another memorable moment.

I don't know how it happened — maybe my patient was a chicken thief pursued by an angry farmer or an errant lover surprised by his paramour's husband. I do know he must have been running the other way when he caught a piece of buckshot in his buttock. I located the buckshot with an X-ray, scrubbed the area, anesthetized it, probed, found, and removed the chunk of metal. I held the forceps high above the sterile stainless pan and dropped the piece of buckshot. It made the same satisfying "clink" you hear in the movies. Pleased with myself, and realizing I might never in my lifetime have the opportunity again, I couldn't resist picking it up and dropping it again. I think the patient enjoyed the drama as much as I did.

The fellow with the buckshot in his butt and innocent wanderers like Eden won my entire sympathy. So did many people who seemed to give life their best but still wound up on the bottom. I had less sympathy for those slackers who declined to work unless the perfect job came along. Others were perpetually angry at the world for not behaving the way they thought it should. They would come in, complain, and were often unhappy with the answers we gave. They'd continue to smoke and overeat, then return with the same complaints. They would ask "Isn't there just some pill you can give me?" They would want us to write notes to miss work when they were well. If they had a musculoskeletal problem, they would not complete the home exercise program to relieve their pain. They stayed in dysfunctional relationships, abusing or being abused.

As well, we attracted quite a few drug seekers. About once a week someone would decide we might respond better if they threatened us or started yelling. We'd call the police. Fortunately the station was right next door and calm would be quickly and quietly restored. We found comfort in the sight of a police uniform.

One woman somehow got herself into the exam room despite a "slipped disk." She couldn't walk; she had all the proper physical findings; I had to put her in the hospital. Her pain did not seem to respond to bed rest and narcotics. The weekend came, and my colleague Eva Jalkotzy took over her care. Eva had worked as a physical therapist until she was thirty-seven. At that time she applied to UCSF medical school. When she received a letter of rejection she walked into the admissions office and said "You're making a mistake, you should accept me. I will be a good doctor." Somehow this changed their minds and she was now, sure enough, a good doctor.

Anyway, when I returned to work Monday, Eva told me she had sent the woman with the back pain home on Saturday. "She had your number. Maybe her back hurts, maybe not, but once I told her how I knew she was exaggerating her symptoms, she got out of bed and walked out of the hospital. Don't feel too bad; those years in physical therapy taught me how to pick out the pretenders."

Sometimes I would see a child on welfare brought in by her grandmother because the child's mother wasn't available. Mother would be off on a binge, on drugs, or with a new boyfriend. I saw several women who never seemed to have matured well enough to be competent mothers to the children they had, yet here they were with another pregnancy.

Our clinic was something of a controlled chaos; those with appointments often failed to come, and others had urgent needs that could not wait for a place in our schedule. Somehow, our nurses fit the whole puzzle together. They were the best. Each of us physicians might see thirty people a day, and much of the credit for this level of productivity went to the nurses. Many of our patients could not be counted on to follow through when given a prescription or lab request. The nurses would explain the whys and wherefores as they mentored them through these complexities. The people coming to see us were often stressed. Sometimes they feared authority. The nurses calmed them. The patients didn't know what their healthcare options were; the nurses guided them to an understanding of what was and was not possible.

The coffee urn in the nurse's station collected all of us when the traffic slowed. One day as we took a break I aired my critique of the welfare system. "It just goes on and on," I said, "nothing ever changes, generation after generation." Mary Gonzales, one of our nurses, looked over at me and said "My father left my mother when I was three. She was on public assistance the whole time my sisters and I grew up. Thanks to the generosity of the state of California, my mother's life was better than it could have been, and I was able to earn my RN. My husband and I both have good jobs and a happy home for our children. The system could use improving, yes, but I'm thankful for it."

Point and game, Gonzales. Fairly won.

So, I learned much there in Red Bluff. Compassion leavened with skepticism. Hope alternating with helplessness. These may have seemed opposites, but we lived with both every day, reconciled both every day. Holistic medicine if ever there was.

I haven't told you yet of the generously stocked pharmaceutical sample closet in the nurse's area — another instance of the ambiguity of life, provided as it was by pharmaceutical companies with their well-known dubious practices.

Yet there it was, and on that day, as I considered Eden's needs, I found myself standing in front of that closet realizing that she did not qualify for involuntary commitment. There was nothing I could do. I chose our most attractive bottle of cough medicine. Introspectively I walked back to the examining room. Her innocent face lit up when she saw it. "Is that good for a hole in the heart?"

I looked at her thin frame, her inadequate jacket, and I hid the hole in my own heart.

"Yes." I handed it to her. "It's the best thing."

All of us at the Monroe Street Medical Clinic wish you a wonderful holiday season. Not a picture-postcard holiday covered with smiling Santas — airbrushed free of sadness, regret, and loss — but a fulfilling interlude of reflection and family celebration, seasoned with compassion.